Health Conditions of the Arab Population in the Occupied Arab Territories, Including Palestine
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FORTY-FIFTH WORLD HEALTH ASSEMBLY Provisional agenda item 34 HEALTH CONDITIONS OF THE ARAB POPULATION IN THE OCCUPIED ARAB TERRITORIES, INCLUDING PALESTINE The Director-General has the honour to bring to the attention of the Health Assembly the annual report of the Director of Health of the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) for the year 1991, which is annexed hereto. ANNEX CONTENTS Page EXECUTIVE SUMMARY 3 1. INTRODUCTION 5 2. GENERAL MANAGEMENT 6 3. EMERGENCY OPERATION IN THE OCCUPIED TERRITORIES AND LEBANON 8 4. MEDICAL CARE SERVICES 10 5. HEALTH PROTECTION AND PROMOTION 19 6. NURSING SERVICES 24 7. ENVIRONMENTAL HEALTH SERVICES 31 8. NUTRITION AND SUPPLEMENTARY FEEDING SERVICES 33 9. CONCLUSIONS AND FUTURE DIRECTIONS 35 Annex EXECUTIVE SUMMARY 1. After an Introduction which provides some background concerning UNRWA and its health policies, the chapter on General Management describes how the Health Department is staffed and organized, the role of the World Health Organization, and the Department's budget and finance 1990, 1991 and the 1992/93 biennium. A brief account of staff training follows and the chapter closes with a table showing the categories, 2. The chapter on Emergency Operation in the Occupied Territories and Lebanon provides an overview of the situation in the Occupied Territories of Gaza and the West Bank during the fourth year of the Intifada which was characterized by the sustained level of violence and unrest, rapid worsening of economic conditions in the aftermath of the war in the area of the Persian Gulf, and increased settlement activities. An update on the number of casualties inflicted on the population as a result of confrontations with Israeli security forces and killing of alleged collaborators is also provided. 3. The trend shows a relative decline in numbers compared to early days of the Intifada, which is partly due to the prolonged comprehensive curfews and restrictions on movements. This chapter also provides a brief description of the situation in Lebanon which in spite of marked improvement remains anything but normal and a brief account of UNRWA's emergency and extraordinary measures in these three Fields. 4. Chapter 4 on Medical Care Services deals with what used to be called (rather hopefully) "curative" medical services, that is all the services, medical, dental，in-patient and out-patient provided in UNRWA，s health centres, health points and contracted or associated hospitals, with the notable exception of ”preventive" services such as communicable disease control, maternal and child health care, immunization etc. described in Chapter 5. In the account of Medical Care Services it can be seen that medical consultations agency-wide in 1991 numbered for the first time over 4 million, an increase of 7 per cent, double that which could be expected from natural growth. The increase in the Gaza Field actually exceeded 23 per cent. This is cause for concern, for already the previous year the average number of daily consultations per medical officer in our health centres was over 100，a figure not compatible with adequate quality of care. This problem and how to solve it is the focus of much current effort, some of which is described, including the start of all day (7.00 hours till 19.00 hours) full service which we hope will begin to be provided at the ten most crowded health centres in the five fields in 1992-93. Much progress including 6 new health centres, and 6 new health points (part-time centres) were provided as well as capital projects, infrastructure and hospital renewal. 5. 1991 was the first year of the UNRWA's greatly expanded programme of care for diabetics, and the number of diabetic patients under our care rose by 4200 to 18 900, indicating a significant impact on the unmet need for this level of care. 6. Within Medical Care Services there was a 45% increase in dental consultations, no doubt due to provision of 13 new dental clinics and units. Seven new health centre laboratories were provided, necessary not only to cope with increased general work but especially that connected with new strategies in diabetes and anaemia. 7. The Commission of the European Communities announced in November 1991 its commitment to fund the construction of the new Gaza Hospital for which UNRWA still seeks the costs of equipment, running costs for three years and support to the establishment of a nursing school. This hospital is very desperately needed. Despite having the largest most dependent population of refugees in the Gaza Field, UNRWA spends relatively little on hospitalization there because of the simple lack of accessible facilities to supplement the low bed/population ratio of government hospital facilities. In the other four Fields on the other hand, particularly Lebanon and West Bank, the Health Department is engaged in a constant and wearing struggle to control its hospitalization costs and ensure primacy for primary health care. 8. In the chapter on Health Protection and Promotion some very encouraging trends indeed can be noted. The steady decline in immunizable diseases continued along with the maintenance of very high immunization Annex levels (near 100 per cent of the infants registered at UNRWA Health Centres) and new vaccination strategies. Hepatitis В will hopefully be added to the EPI vaccines at the same time as the host governments and the Israeli Government add it for their own populations. 9. A strong effort was made to redefine goals and strategies in maternal health and family planning care, with some assistance of UNFPA, and some results of this effort will undoubtedly be seen in 1992. 10. Most encouraging were the results of meticulous surveillance of nutritional status of children under three. We may confidently say that as far as 1991 was concerned, despite the deprivation of the Gulf War, no field has any longer a problem of protein-energy malnutrition, except for our refugee infants in Syria. In that field it exists to a mild degree (4.2 per cent below minus 2 standard deviations below the mean weight for age as compared with an expected 2.6 per cent). In retrospect it was probably a wise decision of the Agency, on the recommendation of the Directors of Health and Relief, to make in January to June a massive distribution of food aid, supplied by donors in response to UNRWA's appeal, which included 30 000 tons of flour, 1575 tons of rice, 1475 tons of powdered milk and about 3000 tons of oils/fats. At that time not only had refugees lost thousands of labouring jobs in the Occupied Territories, millions in remittances of family members in the Persian Gulf area, but thus were also for weeks confined to their homes under curfew unable even to shop. However, the child population fortunately survived with no sign whatever of malnutrition. 11. Among expansions of the Department's work are the early stages, in West Bank and Gaza at least of what will grow to be an Agency-wide programme of Mental Health, whose absence for so long from the UNRWA programme is rather inconsistent with the WHO definition of health. 12. Many of the considerable expansions in services described in these two chapters on Medical Care Services and Health Protection and Promotion although they are inadequate to meet the rising demands and expectations, could not even have been possible without the diversion of resources from the midday meal programme to increases in primary health care coverage and quality. 13. Chapter 6 on the Nursing Services describes considerable changes in orientation to a wider context of community health and a most industrious and fruitful effort in a variety of aspects of the whole Health Department programme (Training, Distance Education, Programme Evaluation, Risk Approach) going well beyond the confines of the earlier traditional approach to Nursing. 14. In Environmental Health Services, while there have been the sort of minor improvements characteristic of all years, this remains one of the weakest points in the whole programme of UNRWA. If it were not for the fact that the host governments in the Syrian Arab Republic and Jordan largely solve the problems by their participation in water and sanitation for refugee camps, we would be in an intolerable situation. As it is now, UNRWA is focusing its efforts on Gaza, West Bank and Lebanon. Intensive assessment is taking place and planning has begun (in Lebanon for example). The donor community will soon have the opportunity to demonstrate its commitment to human wellbeing and development in these three Fields by relieving their distressing situations in respect of water and sanitation, the worst being that of Gaza. 15. In the final chapter Conclusions and Future Directions, the Director of Health attempts to analyse some aspects of the experience of 1991, and beyond this to point out some of the more fundamental constraints affecting the achievement of WHO and the Department's ideals and arising from the nature of UNRWA's history and mandate, and indeed the nature of the Palestine refugee problem. Nevertheless, he also tries to point out the main lines along which the Health Department should strive to progress between now and the end of the decade. Annex 1. INTRODUCTION 1.1 Population Overall the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) cares for just over two and a half million registered refugees as at 30 June 1991, of whom more than one-third live in camps while the rest live in cities, towns or villages. The registered refugee population is distributed as follows: Lebanon 310 000, Syrian Arab Republic 290 000, Jordan 960 000, the West Bank 430 000 and the Gaza Strip 529 000.